posted at 4:41 pm on July 3, 2014 by Noah Rothman

While it is just a tragic anecdote, the latest story surrounding the chronic and too often fatal inefficiency of Veterans Affairs hospitals is illustrative of a much larger problem.

“A veteran who collapsed in an Albuquerque Veteran Affairs hospital cafeteria, 500 yards from the emergency room, died after waiting 30 minutes for an ambulance,” the Associated Press reported on Thursday. “Officials at the hospital Thursday confirmed it took a half an hour for the ambulance to be dispatched and take the man from one building to the other, which is about a five minute walk.”

VA spokeswoman Sonja Brown defended the VA’s conduct in this case, telling reporters that the staff “followed policy in calling 911 when the man collapsed on Monday.” She added, however, that this policy is now under review.

It is unclear why the ambulance took so long to reach this veteran in need, and blaming the VA system in this instance may be entirely unfair. That said, it is also just another example that serves to reinforce the narrative that the VA system is hopelessly broken.

And the impression that the VA system is broken is anything but unfair.

“The chief medical inspector for the Department of Veterans Affairs has retired, following a report that his office downplayed whistleblower complaints outlining serious problems at VA facilities across the country, acting VA Secretary Sloan Gibson said Wednesday,” another Associated Press report published Wednesday read. “Dr. John R. Pierce had served as medical inspector since 2004 and was deputy medical inspector for two years before that.”

Pierce is one of a half-dozen high-ranking officials who have resigned or retired from the VA following a national outcry over reports of patient deaths, widespread treatment delays and falsified records at VA facilities nationwide. The outcry led to VA Secretary Eric Shinseki’s resignation in late May. Since then, several other officials have resigned, including the agency’s top health official and the man who replaced him as acting undersecretary for health. A third man who had been nominated by Obama for the top health job withdrew.

Obama’s new nominee to head the VA, former Procter & Gamble CEO Robert McDonald has his hands full. Those who are hoping that McDonald will turn the VA around and run this Leviathan federal agency like a business will be sorely disappointed. Federal bureaucracies are impervious to the market forces which make businesses run like businesses.

In late June, the CNN reporter who originally broke the story surrounding falsified waiting lists at the VA, Drew Griffin, expressed his doubts that the VA can fix itself. “I don’t know how you fix this. I really don’t know, if I was going to give advice, where you would give it, other than I would blanketly throw out every senior manager in the VA,” he said.

That process seems to be underway, though it remains to be seen if that will be enough.

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Pierce is one of a half-dozen high-ranking officials who have resigned or retired from the VA following a national outcry over reports of patient deaths, widespread treatment delays and falsified records at VA facilities nationwide. The outcry led to VA Secretary Eric Shinseki’s resignation in late May. Since then, several other officials have resigned, including the agency’s top health official and the man who replaced him as acting undersecretary for health. A third man who had been nominated by Obama for the top health job withdrew

I’ve worked in hospitals for 25 years. For someone to die in the cafeteria, while some career shill insists “policies were followed”, should be enough to get a wagonload of people fired at that facility.

Which will never happen.
Don’t fix the va. Burn it. Fire everyone. Give vets a Medicare card and a fixed supplemental secondary. Period.

It is unclear why the ambulance took so long to reach this veteran in need, and blaming the VA system in this instance may be entirely unfair. That said, it is also just another example that serves to reinforce the narrative that the VA system is hopelessly broken.

No, it is an indictment on those who would let someone else solve the problem that was right before them, or, worse, prevent someone from doing so. Surely those near this man could have carried him to the emergency room had they been allowed to.

“A veteran who collapsed in an Albuquerque Veteran Affairs hospital cafeteria, 500 yards from the emergency room, died after waiting 30 minutes for an ambulance,” the Associated Press reported on Thursday. “Officials at the hospital Thursday confirmed it took a half an hour for the ambulance to be dispatched and take the man from one building to the other, which is about a five minute walk.”

Um…. That five minute walk wasn’t a one-way street. If the veteran come to the hospital, why didn’t the hospital come to the veteran?

I won’t weigh in to the bigger policy issue about simply calling 911 in these situations but I will say that the VA is going to write a very large check to the family. It’s one thing if the patient dies in the ambulance on the way to the hospital, another thing entirely when the patient dies in a HOSPITAL waiting for an ambulance.

We hear stories of private employees being fired for being Good Samaritans, and we hear of medical dispatchers refusing to even call for assistance because they are on their breaks — and having such decisions upheld in the courts.

There’s no law requiring one to be a Good Samaritan, but the laws should not punish those who would be.

No, it is an indictment on those who would let someone else solve the problem that was right before them, or, worse, prevent someone from doing so. Surely those near this man could have carried him to the emergency room had they been allowed to.

unclesmrgol on July 3, 2014 at 4:56 PM

I tend to agree with your comments but think that we don’t know everything about the situation. I doubt the protocol was to simply call 911 and put orange cones around the collapsed diner until an ambulance shows up. Maybe he was being tended by medical professionals during the wait.

Nevertheless, 30 minutes waiting for an ambulance would have been plenty of time for people to act like human beings. I’m more inclined to blame the system than the people at this point.

It is unclear why the ambulance took so long to reach this veteran in need, and blaming the VA system in this instance may be entirely unfair. That said, it is also just another example that serves to reinforce the narrative that the VA system is hopelessly broken.

But, but, BUT!!!! The VA is such a great example of government provided healthcare, says obaka noncare lovers!!!!!!

It is unclear why the ambulance took so long to reach this veteran in need, and blaming the VA system in this instance may be entirely unfair.

No, it is ENTIRELY fair to blame the VA for drafting and implementing such a fupped-duck policy like this to start with! Even getting a security guard off of parking lot patrol duties to drive a person in medical distress to the ER ON PREMISES would’ve been preferable to following such a dipstick-inspired (but but LAWSUIT! ACCOUNTABILITY!) *ahem!* protocol.

We now know one of the top priorities for Robert McDonald. Setting up places in VA cafeterias so that veterans can die more efficiently. At least this veteran was getting treatment unlike the veteran who finally got an appointment two years after his death.

Seriously, it is insane to think that a guy who spent a career pushing soap and detergent on the merits of its lemon scent has the skills to turn the VA around. McDonald was not given the tools to make real changes to a system that would let people die in hospital cafeterias.

I think the policy referred to was probably that when an emergency arises (i.e. someone collapses), on the grounds, all hospital employees are to wait for emergency services to arrive to check out and transport the patient to the emergency room. The idea is likely that, given the broad range of “incidents” that could occur, having possibly unqualified and/or unequipped employees attempt to treat or transport a patient would be both a danger to the patient and expose the employee and/or hospital to liability (for any mistakes the employee made).

Like a lot of things, you can easily come up with circumstances where the prudent policy proves to have bad to fatal consequences.

I think the policy referred to was probably that when an emergency arises (i.e. someone collapses), on the grounds, all hospital employees are to wait for emergency services to arrive to check out and transport the patient to the emergency room. The idea is likely that, given the broad range of “incidents” that could occur, having possibly unqualified and/or unequipped employees attempt to treat or transport a patient would be both a danger to the patient and expose the employee and/or hospital to liability (for any mistakes the employee made).

Like a lot of things, you can easily come up with circumstances where the prudent policy proves to have bad to fatal consequences.

Russ808 on July 3, 2014 at 5:25 PM

True, but in this case you call for emergency service internally. They could have brought a gourney from the ER in just a few minutes. But robots will do as robots do.

Which is more outrageous? That he was left to die like that or the official who says employees “followed hospital policy”?!!

The hospital where I work has a series of emergency codes, one of which is “Visitor Down”. When that code comes over the paging system, a designated Emergency Room team GOES TO WHERE THE PERSON IS….we DO NOT wait for the patient to be brought to us!!!!!

Are VA hospitals subject to any kind of accreditation or certification, like that provided by The Joint Commission? Are they held to any standard whatsoever? From what I’m reading, it appears not.

Any private hospital that operated like this would be fined, closed and probably prosecuted!

BTW, I do some work at a PSYCH hospital. When there is a medical emergency, which is called “code blue”, people from every department run with assigned duties to the location of the emergency. 911 is called. There mostly nurses, mental health therapists and techs. Doctors may or may not be there. We ATTEND to the patient until 911 arrives i.e. CPR, oxygen, etc

I think the policy referred to was probably that when an emergency arises (i.e. someone collapses), on the grounds, all hospital employees are to wait for emergency services to arrive to check out and transport the patient to the emergency room. The idea is likely that, given the broad range of “incidents” that could occur, having possibly unqualified and/or unequipped employees attempt to treat or transport a patient would be both a danger to the patient and expose the employee and/or hospital to liability (for any mistakes the employee made).

Like a lot of things, you can easily come up with circumstances where the prudent policy proves to have bad to fatal consequences.

Russ808 on July 3, 2014 at 5:25 PM
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True, but in this case you call for emergency service internally. They could have brought a gourney from the ER in just a few minutes. But robots will do as robots do.

The idea is likely that, given the broad range of “incidents” that could occur, having possibly unqualified and/or unequipped employees attempt to treat or transport a patient would be both a danger to the patient and expose the employee and/or hospital to liability (for any mistakes the employee made). Russ808

Russ – spoken like a guy who has been conditioned by the constant threat of the trial bar to act in ways that are NOT natural or prudent.

We need to check ourselves as human beings as to how far our conditioning and freedom has been infringed. Between the trial bar and thought police, few of us seem to be able to use our God-given talents and voices to act humanely and speak truth.

I worked in an outpatient dept of a hospital that was situated so that the hospital proper, and the outpatient facilities while being next door to each other, were actually in different cities. The expectation was, that if medical issues arose, we were to call the EMS from Grosse Pointe, to take the patient to Detroit……….never happened, if we had any concerns for one of our patients, we’d literally put them in a wheelchair and run them to the ER, policy be damned, the first rule is DO NO HARM.

Need a time stamped transcript of the incident from when someone picked up the phone to call, to when the call was answered, to when the ambulance was dispatched, to when they went enroute and arrived on scene, to when they transported.

There’s a breakdown here. Unless the only available rig was clear across the county, why did it take so long? Who provides EMS service? Was it the local municipality (fire department, rescue squad) or do they employ private services?

Seriously, it is insane to think that a guy who spent a career pushing soap and detergent on the merits of its lemon scent has the skills to turn the VA around.

I think you sell him a bit short, as a CEO of a multinational conglomerate, he has experience managing and directing complex systems, and solving the problems within them. Where he will likely come up short, though, is having to deal with the unions and unfireable GS types. The government employee unions are beyond ridiculous, they will balk at any change no matter how trivial to a job or personnel; without power to fire and reorganize without their interference, he will get nowhere.

When that code comes over the paging system, a designated Emergency Room team GOES TO WHERE THE PERSON IS….we DO NOT wait for the patient to be brought to us!!!!!

Indeed, and that is the standard. According to the story, medical personnel from the Kirtland AFB Medical group (adjacent to the VA) did CPR on the vet for 30 minutes, not VA staff, USAF staff.

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Someone I know works at the Lancaster General Hospital, Lancaster, PA. Their facility received a major addition across Duke St from the Main building. It was all part of a parking garage upgrade, in addition to having some office space for Doctors to practice.
This facility is connected to the Main building across the street by a fully enclosed, bi-level pedestrian bridge.

I was told that if someone at this facility across the street needed to be “rushed” to the Emergency Room, insurance interests require an ambulance to transport the patient across the street. If none are readily available, you wait . . . . . kinda’ like the veteran in this story.

In a VA hospital cafeteria, wouldn’t there be a wheelchair or gurney available to wheel somebody away in an emergency? Why didn’t cafeteria personnel either wheel the man to the emergency room, or call the emergency room directly to have VA paramedics attend to him?

In a VA hospital cafeteria, wouldn’t there be a wheelchair or gurney available to wheel somebody away in an emergency? Why didn’t cafeteria personnel either wheel the man to the emergency room, or call the emergency room directly to have VA paramedics attend to him?

In a VA hospital cafeteria, wouldn’t there be a wheelchair or gurney available to wheel somebody away in an emergency?

Maybe a wheelchair, a gurney, no.

Why didn’t cafeteria personnel either wheel the man to the emergency room, or call the emergency room directly to have VA paramedics attend to him?

You generally don’t want to move somebody if you are not sure what is wrong, unless you have the equipment to stabilize as you go, which is why there should have been a Code called, and the Code team responding, instead of the pick-up team from the clinic next door (not to knock the USAF guys, but I imagine they were just there to eat and didn’t exactly have a lot of gear with them).

I think the policy referred to was probably that when an emergency arises (i.e. someone collapses), on the grounds, all hospital employees are to wait for emergency services to arrive to check out and transport the patient to the emergency room. The idea is likely that, given the broad range of “incidents” that could occur, having possibly unqualified and/or unequipped employees attempt to treat or transport a patient would be both a danger to the patient and expose the employee and/or hospital to liability (for any mistakes the employee made).

Like a lot of things, you can easily come up with circumstances where the prudent policy proves to have bad to fatal consequences.

Russ808 on July 3, 2014 at 5:25 PM

they tried to avoid “danger to the patient” but the patient died anyway…

The VA’s problems did not cause the delay of the EMT it might have caused the delay in him seeing a doctor for his heart condition that caused him to collapse. It would help to know where the delay was. The Ambulance driving to the hospital or calling one. Once it was called it might have got there in the normal 8 minutes but it took 20 minutes to find out they needed to call one.

I was told that if someone at this facility across the street needed to be “rushed” to the Emergency Room, insurance interests require an ambulance to transport the patient across the street. If none are readily available, you wait . . . . . kinda’ like the veteran in this story.

listens2glenn on July 3, 2014 at 6:00 PM

Sadly, this is not unusual. In Scranton there are 3 hospitals. Two have cardiac cath labs. One does not (at least not when I worked there) It was 1 block from a hospital with a cath lab. If a patient came in with a heart attack and had to go emergently to the cath lab, we had to wait for an ambulance to come and transport the patient. (One time it took an hour) The docs didn’t even move their cars to go from one to the other, but the only mechanism for patient transport was wait for the ambulance. I tried to sell the idea of an elevated pedestrian bridge, but didn’t get anywhere.

I think the policy referred to was probably that when an emergency arises (i.e. someone collapses), on the grounds, all hospital employees are to wait for emergency services to arrive to check out and transport the patient to the emergency room. The idea is likely that, given the broad range of “incidents” that could occur, having possibly unqualified and/or unequipped employees attempt to treat or transport a patient would be both a danger to the patient and expose the employee and/or hospital to liability (for any mistakes the employee made).

Like a lot of things, you can easily come up with circumstances where the prudent policy proves to have bad to fatal consequences.

Russ808 on July 3, 2014 at 5:25 PM

Yep…So let’s just do nothing and let the old fart die, eh? Can’t have no law suit now, can we??

I’ve worked in hospitals for 25 years. For someone to die in the cafeteria, while some career shill insists “policies were followed”, should be enough to get a wagonload of people fired at that facility.

orangemtl on July 3, 2014 at 4:52 PM

I work at a hospital lab; there are three buildings, all interconnected through the basement. At two of the buildings, if there’s a medical emergency, it’s handled internally. In the building I work in, if there is an emergency, we have to call 911 and wait for an ambulance to respond.

Unless it’s on the 3rd floor, of course. So we joke that if you’re having a heart attack, drag yourself into the elevator and hit “3”… assuming the call button works (about a 50-50 chance on the 1st floor).

I blame lawyers and cowards for this more than the VA as an institution, since from listens2glenn, talkingpoints, malclave…we see it isn’t just the VA. The ambulance chasers have caused this nonsense where cowards are more concerned about covering their asses than saving lives. Of course, the lawyers need greedy clients, so I guess there is plenty of blame to go around.

orangemtl on July 3, 2014 at 4:52 PM
…………….
My sentiments as well. The VA is beyond fixing. Let’s let Congress deal with the request that vets get the same healthcare as our congressional reps and see how well they handle that one.

The cafeteria is a separate building from the hospital proper. The map the Journal published shows that the 500 yards from the cafeteria to the emergency room involves driving halfway around the hospital. The straight-line distance is only about 200 yards — 100 yards from the cafeteria to the hospital, and another hundred yards inside the hospital building.

The “policy” quoted establishes a Code Blue response team, consisting of a physician, an intensive care unit nurse, a health technician, a nursing supervisor, an anesthesiologist, a respiratory therapist and a pharmacist, if needed. They respond in six buildings in the hospital complex, but not in the cafeteria.

For incidents elsewhere in the hospital complex, the Albuquerque Fire Department is called. The nearest fire station is Station 11, about a mile away. Why it took eleven minutes for an ambulance to travel that distance has not been explained.

In this incident, immediate care was given by Kirtland Air Force Medical Group personnel, who regularly eat lunch at the cafeteria. (The hospital is adjacent to Kirtland AFB). As someone upthread noted, they were eating lunch, not making a call, and probably didn’t have equipment with them. It also raises the possibility that they saw the victim was in such desperate shape that they didn’t dare try to move him to the hospital.

In other words, his death may have been foreordained. Nonetheless, it’s my opinion that it should have taken place in the emergency room — and the VA’s tonedeaf “But it’s POLICY!” should earn someone a good buttkicking. “Expedited policy review,” my Aunt Fanny.